The differential diagnosis of tiredness: a systematic review

Abstract

BACKGROUND: Tiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress,  patients but also their physicians are often uncertain regarding a serious cause  and appropriate diagnostic work-up. We conducted a systematic review and  meta-analysis of studies reporting on differential diagnosis of fatigue in  primary care. METHODS: MEDLINE, EMBASE and conference abstracts were searched for  primary care based studies of patients presenting with tiredness. Twenty-six  studies were included. We report on anaemia, malignancy, serious organic disease,  depression and the chronic fatigue syndrome (CFS) as causes of tiredness as  presenting complaint. RESULTS: We found considerable heterogeneity of estimates  which was reduced by limiting our analysis to high quality studies. Prevalences  were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6-4.8 %); malignancy:  0.6 % (CI 0.3-1.3 %); serious somatic disease: 4.3 % (CI 2.7-6.7 %); depression  18.5 % (CI 16.2-21.0 %). Pooling was not appropriate for CFS. In studies with  control groups of patients without the symptom of tiredness, prevalence of  somatic disease was identical to those complaining of tiredness. Depression,  however, was more frequent among those with tiredness. CONCLUSIONS: Serious  somatic disease is rare in patients complaining of tiredness. Since prevalence is  similar in patients without tiredness, the association may not be causal.  Extensive investigations are only warranted in case of specific findings from the  history or clinical examination. Instead, attention should focus on depression  and psychosocial problems.